New Patient Screening Form - Renewed Outlook

Questions or Concerns?

Please call or text the office if you have any questions or experience any problems while completing this form.

724-302-5969

Important Information — Please Read Before Completing This Form

Renewed Outlook Holistic Mental Health & Wellness is a small outpatient psychiatric practice. This screening form helps us determine whether the practice may be an appropriate fit for your needs. Submitting this form does not guarantee an appointment, begin treatment, or establish a patient-provider relationship.

The practice primarily provides psychiatric evaluation and medication management, with brief supportive psychotherapy incorporated into visits when appropriate. Psychotherapy-only services are generally not available.

Renewed Outlook does not provide emergency or crisis services. If you are experiencing a mental health emergency, call 911, go to the nearest emergency department, or call/text 988.

Please review our website for additional information regarding services, insurance participation, and practice policies.

Insurance Participation

Renewed Outlook participates with many commercial insurance plans, including most BCBS plans, UPMC Health Plan, Aetna and UnitedHealthcare/Optum. We are able to accept many Aetna plans through our partnership with Alma.

We are not accepting new patients with Cigna as primary or secondary insurance coverage.

We do not currently accept Medicaid, Medical Assistance, Medicare, Medicare Advantage, ACCESS, or other government-sponsored insurance plans, including as secondary coverage.

We are currently exploring participation with Medicare and Medicare Advantage plans. If you have Medicare or Medicare Advantage coverage, you are welcome to check back with the practice at a later date for updates regarding availability.

Insurance information will be reviewed as part of the screening process.

Scheduling & Availability

Appointment availability varies based on clinical needs, requested services, location, and current practice capacity. A wait for an initial appointment may apply.

Practice Locations

Erie, PA: The provider is typically available for in-person appointments in the Erie area twice per month, generally on a Tuesday and the immediately following Wednesday morning. Availability may vary by month.

Kittanning, PA: Limited in-person appointments remain available at this location. The Kittanning office will permanently close in early 2027.

Virtual Visits: Telehealth appointments are available throughout Pennsylvania when clinically appropriate.

Pittsburgh Area: Expanded in-person services are planned as an appropriate office location becomes available, with a goal of beginning in late winter or early spring 2027.

Pediatric Services

Generally accepting patients age 12 and older. All pediatric referrals are reviewed on a case-by-case basis.

Before You Begin

This is a dynamic form. Additional questions or sections may appear based on your responses.

If you are completing this form for someone else, or another person is helping complete the form, there will be a separate section to enter that person’s information. Unless otherwise specified, all other questions should be answered about the person who is seeking care.

If you were referred by a therapist or other healthcare provider, please provide their name and contact information, and let us know whether they are aware that you are requesting care with our practice.

Prospective Patient Information

Please enter the information below for the person who is requesting care with our practice.

PATIENT Legal First Name:

PATIENT Legal Last Name:

PATIENT Preferred Name:

PATIENT Date of Birth:

Gender Identity:

Preferred Pronouns:

Street Address:

Apt./Unit #:

City:

State:

Zip Code:

Cell Phone:

Home Phone:

Email:

If you are completing this form on behalf of the prospective patient, please provide your name, relationship to the patient, and contact information.

How do you plan to pay for services?

Self-pay Commercial insurance (such as Highmark BCBS, Anthem BCBS, Independence Blue Cross, UPMC Health Plan, UnitedHealthcare/Optum, Aetna or similar employer-sponsored or private insurance plans)

Insurance Information

Please provide the requested insurance information below. This information is used to verify coverage and determine whether Renewed Outlook participates with your plan. Please enter the information exactly as it appears on your insurance card.

Renewed Outlook does not currently accept Medicaid / Medical Assistance plans, including UPMC for You, Highmark Wholecare, AmeriHealth Caritas, PA Health & Wellness, UnitedHealthcare Community Plan, Aetna Better Health, ACCESS, or similar plans.

We also do not currently accept Medicare or Medicare Advantage plans, including UPMC for Life, Highmark Freedom Blue, Aetna Medicare, UnitedHealthcare Medicare Advantage, Humana Medicare Advantage, or similar plans.

We are not currently accepting new patients with Cigna insurance as primary or secondary coverage.

Primary Insurance Member ID:

Primary Insurance Policy Holder Name:

Primary Insurance Holder Date of Birth:

Do you have secondary insurance coverage? *

Yes No

Secondary Insurance Company Name (if applicable):

Secondary Insurance Member ID (if applicable):

Important Insurance Disclosure

Renewed Outlook makes every effort to identify primary and secondary insurance coverage during the screening and eligibility verification process. Patients are responsible for providing complete and accurate information about all insurance coverage.

Renewed Outlook is unable to provide services to individuals who have Medicaid / Medical Assistance or Medicare / Medicare Advantage coverage, including as secondary insurance.

If this coverage is not disclosed and is identified later, any scheduled intake appointment will need to be canceled. If you have already established care with the practice, you will need to be discharged and transitioned to an appropriate provider.

Please confirm the following:

I verify that I do not have Medicaid, Medical Assistance, Medicare, or Medicare Advantage coverage as either my primary or secondary insurance.

Self-Pay Notice

You have indicated that you plan to proceed as a self-pay patient. Services will not be billed to insurance, and payment is due at the time of service.

If you are uninsured or choose not to use insurance, you have the right to receive a Good Faith Estimate of the expected charges for your care prior to your appointment, in accordance with federal law.

ADHD Evaluation and Treatment Information

Prior diagnosis: If you have already been diagnosed with ADHD, we may request documentation of the diagnosis and/or prior testing or treatment records.
Evaluation: If adequate diagnostic documentation is not available, a thorough ADHD evaluation will be completed; this typically requires more than one visit. Neuropsychological or psychological testing may also be recommended in some cases. Renewed Outlook does not provide neuropsychological testing, but we can provide a list of outside testing resources.
Medication: An ADHD evaluation does not guarantee that stimulant or other controlled-substance medication will be prescribed. Treatment recommendations are individualized, and we use a conservative approach to stimulant prescribing.
Monitoring: Patients prescribed controlled substances are required to attend regular follow-up appointments. Periodic in-person visits and/or urine drug screening may be required.
In-person requirements: Requirements may vary based on practice policy, clinical circumstances, insurance or pharmacy policies, and applicable state or federal regulations.

Please review our Controlled Substance Policy on our website before requesting ADHD treatment.

Disability Evaluations and Related Paperwork

If you are seeking disability-related evaluation or paperwork, please be aware of the following:

Long-term disability and SSI forms: Generally require at least 6 months of established care with this practice. Completion is based on the provider’s clinical judgment and is not guaranteed.
Short-term disability and FMLA forms: Generally require at least 3 completed visits before forms will be considered.
Recent visit required: Patients must generally have been seen within the past 30 days before disability paperwork is submitted.
Ongoing treatment: Continued completion of disability-related paperwork requires appropriate participation in treatment and follow-up.
Processing time: Paperwork may take up to 14 days to complete and cannot routinely be expedited.
Fees: Disability and related forms are subject to a paperwork fee. Please review the Practice Fee Schedule for current charges.
Important: Renewed Outlook may provide clinical information and medical records when appropriate, but we do not guarantee approval for disability, SSI, FMLA, or other benefits.

Please review our full Disability Forms Policy on our website before requesting evaluation or completion of disability-related paperwork.

Substance Use Disorder Treatment Policy

Renewed Outlook does not provide treatment for active substance use disorders.

We do not prescribe Suboxone, methadone, Vivitrol, or other medications specifically for medication-assisted treatment of substance use disorders.
In limited circumstances, oral naltrexone may be considered when clinically appropriate as part of a broader psychiatric treatment plan.
We may be able to provide treatment for co-occurring mental health conditions when appropriate.
When specialized substance use treatment is needed, we can provide referrals or recommend a higher level of care.

Psychotherapy-Only Services

Renewed Outlook is primarily a psychiatric medication management practice and does not typically offer psychotherapy-only services. Brief supportive psychotherapy may be provided as part of medication management when clinically appropriate.

If you are seeking ongoing psychotherapy without medication management, you may wish to:

Contact your insurance company for a list of in-network therapists.
Search for therapists through Psychology Today or another therapist directory.
Ask your primary care provider or another healthcare professional for referral recommendations.

Please briefly describe your concerns, including when they began and how they affect your daily life.

Are you currently receiving psychiatric medication treatment from another provider?

Yes No

For safety and continuity of care, psychiatric medications are generally managed by one prescribing provider at a time.

If you are currently seeing another psychiatric medication provider, please tell us who is managing your medications and whether you are seeking to transfer care, obtain a consultation/second opinion, continue with your current provider, or are unsure.

Are you currently working with a therapist or counselor?

Yes No Not currently, but I'm interested in finding a therapist

Please provide the name of your therapist and/or their practice..

Please list any current psychiatric medications. Include medications for mood, anxiety, sleep, ADHD, or other mental health concerns. If none, enter “none.”

Benzodiazepine Medication Policy

Renewed Outlook uses a conservative approach to benzodiazepine medications such as Xanax, Ativan, Klonopin, and Valium. These medications are not typically prescribed for regular or long-term use. In limited circumstances, a small quantity may be prescribed for short-term or occasional use when clinically appropriate.

If you are currently taking a benzodiazepine regularly, continuation, dose increases, or assumption of long-term prescribing should not be expected and alternative treatment options may be recommended.

In-Person Visit Requirements

Some medications and clinical situations may require periodic in-person visits based on medical or clinical needs, safe prescribing practices, insurance requirements, applicable laws or regulations, or practice policy. These requirements help support safe and appropriate care.

Are you able and willing to attend an in-person visit if required?

Yes No Not sure

If in-person care is required, which location(s) would you be willing to attend? Select all that apply.

Erie (limited availability; generally twice per month)

Kittanning (limited availability; this office will be closing in early 2027)

Pittsburgh Area (a location is expected to be available in late winter or early spring 2027)

I prefer virtual visits whenever clinically appropriate

I am open to any available location as needed

Which visit format do you prefer?

In-person Virtual / telehealth Either / no preference

Do you have any scheduling limitations or availability restrictions we should be aware of?

What to Expect Next

Your form will be reviewed within approximately one week. If additional information is needed, we will contact you. Submission of this form does not guarantee scheduling.

If we believe our practice may be a good fit and an appointment is available, we will contact you to review next steps and scheduling. We must speak with you directly before an intake appointment can be scheduled. Appointments are not scheduled through email or text messaging.

If an intake appointment is offered, required intake paperwork must be completed within 48 hours to confirm the appointment. If paperwork is not completed within that timeframe, the appointment will be canceled and offered to another patient unless other arrangements have been made in advance.

If we believe our practice may be a good fit but no appointments are currently available, you may be placed on a waitlist.

Please ensure your voicemail is set up and able to receive messages. We will make up to two contact attempts using the information provided. If we do not receive a response, your request may be closed.

If we are unable to offer scheduling, we will notify you when possible.

Please make sure you select “Submit” at the end of this form to complete and submit your request. Your form is not submitted until you click “Submit.”

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